WOUND MANAGEMENT CARE PATHWAY

Transcription

1 derby hospitals NHS foundation TRUST WOUND MANAGEMENT CARE PATHWAY Patient Addressogram Admission to Specify Admit from home, Residential/ Nursing/ Hospital Transfer to Ward Transfer to Ward... Clinical Incident Reference no Implement for all patients with pressure ulcers admitted and acquired in hospital Pressure Ulcers It is mandatory that all pressure ulcers grade 2 and above are reported as a clinical incident, complete risk DATIX report indicating whether admitted or acquired in hospital. All grade 3 and 4 pressure ulcers need to be referred to the Tissue Viability Team for assessment and coordination of RCA s (Root Cause Analysis). If a patient is transferred internally to your area with pressure ulcer damage and this has not been identified or handed over on transfer, please report as clinical incident. Patients with pressure ulcers should also have the Pressure Ulcer Preventative and Management Care Pathway. Open Wounds All wounds should be assessed, documented and evaluations recorded in this document. All superficial ulcers associated with incontinence/moisture should be categorised and reported as moisture lesions NOT grade 2 pressure ulcers on Datix. Print Name Job Title Initials IMPLEMENT THIS CARE PATHWAY FOR ALL PATIENTS WITH OPEN WOUNDS G PRESSURE ULCER & WOUND CARE PATHWAY.indd 1 6/7/12 14:55:13

2 How to use IMPLEMENT THIS CARE PATHWAY FOR ALL PATIENTS WITH OPEN WOUNDS 1. Commence pressure ulcer data entry on Pressure Ulcer Incidence Form (page 3) 2. Refer to Pressure Ulcer Classification and Standard Wound Management (page 3) to help you in your assessment and decisions re management 3. Document pressure ulcer and other wound descriptions on Open Wound Description form (page 4) 4. Document wound history and aims and objective of wound management (page 5) 5. If patient has a leg ulcer present, (refer to pages 6 and 7) for Care Pathway, complete details and implement plan based on history and presentation. 6. Document dressing choice in the Inpatient Wound Prescription Section (pages 8-10) 7. Staff need to record rationale (page 8-10) for changing the prescription; example if a wound dries out, it is appropriate to change the prescription from an alginate to a hydrogel in order to hydrate tissue. 8. Objective evaluations need to be recorded at each dressing change on the Pressure Ulcer/Wound Evaluation Form (11-14) 9. If evaluations indicate a deterioration in the ulcer refer to Tissue Viability Team 10. Complete Discharge Section of Pressure Ulcer Incidence and Outcome Form (page 16) Copy this and send copy with patient to support discharge information. Mitigating factors present that support unavoidable status Indicate possible mitigating/ unavoidable factors present which may influence Pressure Ulcer Development Critical illness e.g. multi organ failure Haemo-dynamic or spinal instability e.g. major trauma acute cord compression History of falls or on floor prior to admission Patient unwilling or unable to comply with the care plan i.e. repositioning /equipment Extremes of weight e.g. malnutrition or dehydration Sudden or altered conscious levels (community) Liverpool care pathway or meets the criteria Deterioration in cardiovascular or respiratory e.g. cardiac arrest 2 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 2 6/7/12 14:55:13

3 PRESSURE ULCER INCIDENCE Pressure Ulcers present on admission to hospital Yes q No q Photographed q MRSA swab q MCS Swab q n/a to swab q Referred to Tissue Viability q n/a q Please specify Origin; Own home q Residential home q Nursing home q Community hospital q Acute hospital q Brief History Equipment prior to admission Pressure ulcer acquired in hospital Yes q No q Photographed q Referred to Tissue Viability q n/a q Please specify origin, ward... q other ward in Trust q indicate which ward... Indicate predisposing factors Management Interventions Document descriptive characteristics including size, stage, tissue colour in the Open Wound Assessment Chart. Identify wound objectives and prescribe dressings that will help meet management of objectives. Refer to Pressure Ulcer Classification and Standard Wound Management to guide you on appropriate management Ensure Pressure Ulcer Preventative and Management Care pathway is implemented Complete Wound Care Evaluation form on each dressing change so that any adverse changes are easily detected and acted upon. If the wound fails to make expected progress or if wound deteriorates refer to Tissue Viability Team. Stage2 pressure ulcers/superficial damage Superfical Moisture Lesion covered with red/ pink healthy tissue. Not Pressure Damage WOUND CLASSIFICATION AND STANDARD WOUND MANAGEMENT All stage 1 damage should be monitored closely and offloaded from pressure- dressings are not required as skin intact Superficial Pressure ulcer uniform shape stage 2 covered with pink healthy tissue Full thickness ulcer (stage 3 or 4) covered with red/pink granulation tissue Stage 3 and 4 pressure ulcers need to be referred to TVN Team Full thickness ulcer (stage 3 or 4) covered with slough or moist devitalised tissue Full thickness ulcer unable to determine extent of damage as wound hidden by necrotic tissue Care with moving and handling/ continence management. Apply Cavilon barrier to good skin, frequent toileting Reposition/offload and support heels when moving in bed, check foot wear Offload pressure/ shear. Restrict sitting. Profile bed to distribute weight. Ensure nutrition balance Offload pressure/ shear support heels when moving. Check how patient moving in bed/ chair Occult damage, likely to be grade 4 photograh refer to TVN, Reduce head height so as to minimise high intensity pressure Protect fragile tissue Protect fragile tissue Protect fragile tissue Rehydrate slough Promote debridement Moist wound bed dress with Non adherent + film pad dressing Wet wound dress with Adhesive foam dressing Exceptions Moist wound bed dress with non adherent + pad film dressing or adhesive foam If wound bed dry dress with Hydrocolloid Moderate exudates dress with alginate and film dressing Wet wound dress with alginate + adhesive foam Dry wound bed dress with Hydrocolloid (if not diabetic) or Hydrogel to rehydrate dry slough Wet slough dress with alginate + film Protect surrounding skin with Cavilon, dress with Alginate, Absorbent pad and film dressing. Refer fot surgical opinion If infection is suspected, swab mc+s consider silver dressing access via pharmacy Heel ulcers covered with dry necrotic eschar /scab should be offloaded and conservatively managed by keeping wound dry; refer for vascular studies. Dry gangrenous toes should be kept dry to facilitate natural auto amputation with minimal risks of infection 3 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 3 6/7/12 14:55:14

4 Record location, aetiology and description of all wounds including qpressure ulcers, wskin tears, eleg ulcers, rdiabetic foot ulcers, tischaemic foot ulcers, yabscess, udehisced surgical wounds, ifungating wounds, ohaematoma, aexcoriation, smoisture lesion, d Only Pressure Ulcers should be graded using the EPUAP classification all other wounds should be classified as either superficial or full thickness Depth of tissue loss R I G H T Superficial skin loss = as in a scratch, abrasion or de-roofed blister POSITION OF WOUND ON BODY LEFT Full thickness skin loss = down to muscle or bone as in a deep crater or cavity COLOUR OF WOUNDS The colour of the tissue within a wound helps us determine the phase of wound healing and monitor wound progress. A B S OPEN WOUND DESCRIPTION Pink wounds = Epithelialising wounds, presence of epithelial cells, migrating from the wound margins or central islands to cover wound Red wounds = Granulating wounds, deep red (raw steak) coloured tissue within the wound bed C D Yellow wounds = Sloughy wounds, wound bed contains a viscous adherent slough, which is generally yellow in colour. Black wounds = Necrotic tissue, wound bed contains devitalised (dead) tissue, usually black, brown, grey Wound Sites use above descriptions to document wound characteristics Wound NO. 1 2 F DATE wound identified 28/08/10 04/08/10 Location Left leg Sacrum Type of wound / Aetiolgy e q Size 3 X 6cm EXAMPLE 2 X 1 Depth /stage Color of tissue S Stage 2 - B Initals PM PM LEFT FOOT LEFT FOOT RIGHT FOOT RIGHT FOOT 4 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 4 6/7/12 14:55:14

5 HISTORY OF WOUNDS Indicate history of wounds relating to trauma? If skin tears/flaps refer to pre-tibial laceration guidelines TV website for appropriate guidelines Indicate wounds relating to post operative dehiscence. Known dressing/tape allergies... If leg ulcer, refer to Leg Ulcer Care Pathway to ensure appropriate referrals, assessment and management District Nurse contacted date... Dressings used prior to this admission to hospital? Estimated duration of wounds: Days... Weeks... Months... Years... Not Known... Photograph Taken... N/A q MC+S SWAB taken... M.R.S.A SWAB taken... Brief history... Co-morbidities... AIMS OF THE WOUND MANAGEMENT Wound No/s Initals To prevent further deterioration in tissue damage To promote healing by secondary intention Objectives of wound Management Infection present yes q no q Indicate factors present which predispose to critical colonization or infection particularly MRSA bacteraemias. Age and general health status, poor nutritional status, severity and size of the wound, local slough and necrosis. diabetes, poor circulation, immune system compromised, medications, prolonged length of stay in hospital, life style e.g. smoking To provide the optimum environment for healing To minimise risks of infection / complications, such as, pain/ discomfort To manage symptoms in line with conservative or palliative care Dressing choices should be made based on wound objectives, example necrotic and sloughy wounds need debriding, choose dressings such as hydrocolloids/ hydrogels that will help rehydrate dead tissue. 4WOUND NO/S. DRESSING OBJECTIVES A B C D E F G H I Protection OBJECTIVES OF WOUND MANAGEMENT Maintenance of a moist wound surface Thermal insulation Absorbs excess exudate Rehydrates wound site Debrides necrotic tissue Debride slough from wound Obliterates dead space Helps to control or eliminate infection J To manage wound symptoms in line with palliative care / conservative care K (please state) 5 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 5 6/7/12 14:55:14

6 CARE PATHWAY FOR PATIENTS ADMITTED WITH LEG ULCERS Ward... Admission...time... Initiated By... 4Wound Swab q MC&S q MRSA q 4Photograph q SECTION 1: ADMISSION ASSESSMENT - ESTABLISH AETIOLOGY Patients admitted with chronic leg ulcers from the community will usually have a plan of care established, wherever possible continue this plan Contact District Nurse Liaison on within 24 hours of admission and ask the following questions Give patient details and GP with a contact number for the ward. Alternatively ask the patients relatives to bring in the district nurse care plan Contacted by What is the current management dressing? Has Patient had a full Leg Ulcer Assessment including ABPI in past 3 months? What is the underlying cause of the leg ulcer? Is the ulcer getting better? Or is it deteriorating? Yes ABPI > 0.8 And patient/ family/ local wound indicates recovering ulcers Continue DN Management Plan Indicate what this includes Skin care Primary dressing Secondary dressing Retention bandages Assessment or ABPI not undertaken within past 3 months refer to Clinical Measurement for ABPI and Dermatology for assessment Referred of ABPI Prior to procedure Apply, light dressing covered with cling film and sterile paper to facilitate procedure Results: Unknown Cause or patient has developed problems during inpatient stay Increased pain, or exudate, Eczema, allergy, infection. Staff unsure of how to manage? Venous Leg Ulcer managed with graduated compression Refer to Dermatology on ext for full leg ulcer assessment Or continuity of compression bandages Provide Dermatology with history prior to admission Leave bandages intact and arrange continuity of care s Arterial/ Mixed Diabetic/ Renal ABPI If Compression bandages have to be removed due to infection, increased pain, circulation Assess wound care needs and refer to section 2 on management flowchart Monitor wound care changes/ progress ie size, tissue type, exudate levels on evaluation form at each dressing change If Infection/ devitalized tissue not making expected progress after 5 days antibiotics refer to Tissue Viability Ulcer Improving Document ulcer descriptive factors in pathway and continue current management Established plan in place No plan in place Refer to doctor for vascular assessment and treatment plan Referral Ulcer deteriorating Document wound details in care pathway photograph and report changes and possible causes. Refer to appropriate specialist 6 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 6 6/7/12 14:55:14

7 SECTION 2: STANDARD CARE INTERVENTIONS FOR PATIENTS WITH LEG ULCERS Risk Issues Skin rehydration or protection Assess wound care needs and record descriptions on wound assessment section of pathway Safe bandage technique Evaluate wound progress so as to detect changes Minimize complications Care Interventions Cleanse and Moisturize skin with bland emollient e.g.(circle to indicate) WSP/LP 50:50, Diprobase, or Epaderm Check heels, ankles, shins for bandage or pressure damage each dressing change, report changes to nurse in charge Document wound assessment details including size of ulcers, type of ulcer superficial or full thickness (do not grade) % tissue type on wound assessment care pathway Prescribe ongoing dressing management in pathway based on classification and exudate levels see section 3 wound management flowchart to help select appropriate dressings. Apply dressings - 5 Bandage starting at the toes and ending just below the knees using a 50% spiral overlap using: orthopedic wool bandage e.g. Formflex followed by crepe bandage e.g. K- lite, hospicrepe 6 Reassess and document evaluations on wound evaluation form, indicating size, tissue type, increasing exudate and outcomes IE, improved, static deteriorated at each dressing change. Report and refer appropriately Where possible patients should be kept mobile but encouraged to rest for periods of time on the bed or to have legs elevated on a stool when sitting. Ensure heels are offloaded to help avoid pressure damage Monitor for increasing signs of cellulites and systemic signs of infection - refer to medical staff If wounds fail to make realistic expected progress refer to appropriate discipline/ specialist If delays in establishing community plan, dress wound with Atrauman, Zetuvite, toe to knee Formflex and Hospiform bandage / started /time resolved & SECTION 3: STANDARD WOUND MANAGEMENT FLOW CHART FOR LEG ULCERS Dry, sloughy necrotic Hydrocolloid Hydrogel with Atrauman Sloughy/ necrotic Moist sloughy necrotic or Alginate depending on exudate Aquafibre Granulating High exudate or Supra Absorbants Aquafibre Foam *Infected Medium exudate Foam Alginate Hydrocolloid Hydrogel Epithelialising No/low exudate Low adherent dressing Hydrocolloid When in doubt Atrauman is a safe temporary dressing until you decide your objectives. Do not use Telfa, or Menolite directly on leg ulcers as they stick and are not absorbent *Infected= generally unwell, systemic signs, pyrexia as well as localised pain at wound site, oedema, increased exudate + odour Swab MC&S + antibiotics Infected wounds should normally be changed daily unless otherwise advised by specialist s nurses. Apply first line antimicrobial and if fails to respond refer on to Tissue Viability Comments G PRESSURE ULCER & WOUND CARE PATHWAY.indd 7 6/7/12 14:55:14

8 Inpatient Wound Management Prescription Document in this section each time that wound is redressed /Ward Wound Dressings Change Review frequency /Ward Wound Dressings Change Review frequency /Ward Wound Dressings Change Review frequency 8 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 8 6/7/12 14:55:14

11 Pressure Ulcer/ Wound Evaluation Progress Sheet Document wound characteristics by ticking or numbering changes observed at each dressing change Review date assessed Wound No Wound length Wound width Wound Depth Wound Type Superficial skin loss Full thickness wound Blister intact Blister de-roofed Crater wound Cavity wound Sinus wound / Tendon / bone exposed Undermining/ tracking present Haematoma or fragile bleeding wound Ischaemic Wound Bed (indicate approximate amounts of tissue in %) example 40% slough Epithelialisation (pinkish white cells) Granulation Tissue( red raw) Sloughy (yellow/whitish) Infected (green /grey) Necrotic (black/ brown/grey) Exudate Type 1 = serum..2 = blood 3 = Pus Approx. amount 1 = none.2 = low 3 = medium, 4 = high, 5 = excess Odour 1 = none 2 = unpleasant, 3 = offensive Surrounding skin Blanching erythema Non blanching erythema Oedema present Frail tissue thin skin Excoriated Macerated Applied Infection suspected 1 = Wound swab sent, 2 = No infection present 3 = Infection confirmed Pain at wound site (1 =no) (2 = yes) Pain Frequency 1 = none, 2 = Intermittent, 3 = at dressing changes, 4 = continuous Outcome of dressing treatment 1 RESOLVED 2= IMPROVED, 3 = NO CHANGE, 4 = DETERIORATED Assessed By Patients Name... Hospital No...Ward... Hospital G PRESSURE ULCER & WOUND CARE PATHWAY.indd 11 6/7/12 14:55:14

15 Evaluation/ Progress 15 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 15 6/7/12 14:55:15

16 WOUND INCIDENCE ON DISCHARGE PLEASE AFFIX PATIENTS STICKER HERE Hospital... Ward... of Admission... Transferred to... date... of Discharge... to... Waterlow on Admission... Please specify main risk factors / issues Clinical Incident IRI REF NO... RCA completed yes q no q n/a q Pressure Ulcers on Admission q yes; Photographed on admission q Please specify Origin; own home q Residential home q Nursing Home q Community Hospital q Acute hospital q Pressure ulcer acquired in hospital qyes; Photographed on discharge q Please specify origin, ward q other ward in Trust q indicate which ward... Indicate type of ulcer if NOT pressure ulcer. eg Specify... refer to page 4 - wound types Indicate location of ulcers on admission or as acquired in Trust RIGHT Anterior LEFT Posteroir RIGHT COMPLETE OUTCOMES EVALUATION OF WOUNDS AND SEND COPY WITH PATIENT ON DISCHARGE Ulcer no Example ID 3/2/81 Atiology LOCATION Skin tear L shin SIZE 3 X 2 X 3 GRADE - Full thickness F Superficial - COLOUR DRESSINGS OUTCOMES ON DISCHARGE Yellow Hydrogel COMPLETE ON DISCHARGE Waterlow Nutrition in bed Indicate risk scores and current management Identify with 4equipment required to support discharge Equipment Arranged by TTO dressings supplied 2 *Outcomes*; 1 = Improved. 2 = Static, 3 -= Deteriorated, 4 Resolved NON REQUIRED REFUSED EQUIPMENT CUSHION sat out SPECIAL FOAM MATTRESS Continence status ALTERNATING TOPPER of Expected Delivery Movement and handling ALTERNATING REPLACEMENT Send completed copy of this page on discharge to Community Carers DN Team or other care setting. Fax copy to Acute Tissue Viability Team Fax no of pre discharge assessment... General Comments... It is mandatory for general wards to complete this for all patients with pressure ulcers. Use open wound management plan for other wounds such as leg ulcers, diabetic/ischaemic foot ulcers 16 G11455/0612 G PRESSURE ULCER & WOUND CARE PATHWAY.indd 16 6/7/12 14:55:15